Consolidated CDA
3.0.0-ballot - ballot
Consolidated CDA
3.0.0-ballot - ballot
This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PatientReferralAct | Version: 3.0.0-ballot | |||
| Draft as of 2023-12-21 | Computable Name: PatientReferralAct | |||
| Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.22.4.140 | ||||
This template represents the type of referral (e.g., for dental care, to a specialist, for aging problems) and represents whether the referral is for full care or shared care. It may contain a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-priorityCode: SHOULD contain priorityCode should-author: SHOULD contain author |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
   templateId:patient-referral-act | 1..1 | II | ||
  @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.140 | |
  @extension | 0..0 | |||
 @classCode | 1..1 | cs | Fixed Value: PCPR | |
| @moodCode | 1..1 | cs | Binding: Patient Referral Act moodCode (required) | |
| id | 1..* | II | In the case of a Consultation Note where this referral is being fulfilled by this consultation, this id would be referenced in the inFullfilmentOf/order/id of the Consultation Note. | |
| code | 1..1 | CD | Binding: Referral Types (required) | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
 reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the time when the future referral is intended to take place. | |
| priorityCode | 0..1 | CE | ||
 author | 0..* | AuthorParticipation | Base for all types and resources | |
| participant | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Fixed Value: REFT | |
 participantRole | 1..1 | ParticipantRole | ||
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). Slice: Unordered, Open by profile:observation | |
 entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents whether the referral is for full or shared care. | |
 @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
 observation | C | 1..1 | Observation | should-priorityCode: SHOULD contain priorityCode |
| @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: RQO | |
| code | 1..1 | CD | ||
| @code | 1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | Fixed Value: completed | |
| priorityCode | 0..1 | CE | Binding: ActPriority (preferred) | |
| value | 1..1 | CD | Binding: Care Model (preferred) | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.moodCode | required | PatientReferralActMoodCode |
| Act.code | required | ReferralTypes |
| Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
| Act.entryRelationship:entryRelationship1.observation.value | preferred | CareModel |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-priorityCode | warning | Act, Act.entryRelationship:entryRelationship1.observation | SHOULD contain priorityCode : priorityCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-priorityCode: SHOULD contain priorityCode should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
| templateId:patient-referral-act | 1..1 | II | ||
 @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.140 | |
| @classCode | 1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: PCPR | |
| @moodCode | 1..1 | cs | Binding: Patient Referral Act moodCode (required) | |
| id | 1..* | II | In the case of a Consultation Note where this referral is being fulfilled by this consultation, this id would be referenced in the inFullfilmentOf/order/id of the Consultation Note. | |
| code | 1..1 | CD | Binding: Referral Types (required) | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the time when the future referral is intended to take place. | |
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| participant | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: REFT | |
| participantRole | 1..1 | ParticipantRole | ||
| @classCode | 1..1 | cs | Binding: RoleClassRoot (required) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). Slice: Unordered, Open by profile:observation | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents whether the referral is for full or shared care. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| observation | C | 1..1 | Observation | should-priorityCode: SHOULD contain priorityCode |
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: RQO | |
| code | 1..1 | CD | Binding: ObservationType (example) | |
| @code | 1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| priorityCode | 0..1 | CE | Binding: ActPriority (preferred) | |
| value | 1..1 | CD | Binding: Care Model (preferred) | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | C | 1..1 | Indication | Base for all types and resources |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.classCode | required | Fixed Value: PCPR |
| Act.moodCode | required | PatientReferralActMoodCode |
| Act.code | required | ReferralTypes |
| Act.statusCode | required | ActStatus |
| Act.priorityCode | example | ActPriority |
| Act.participant.typeCode | required | Fixed Value: REFT |
| Act.participant.participantRole.classCode | required | RoleClassRoot |
| Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Act.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: SUBJ |
| Act.entryRelationship:entryRelationship1.observation.classCode | required | Fixed Value: OBS |
| Act.entryRelationship:entryRelationship1.observation.moodCode | required | Fixed Value: RQO |
| Act.entryRelationship:entryRelationship1.observation.code | example | ObservationType |
| Act.entryRelationship:entryRelationship1.observation.statusCode | required | ActStatus |
| Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
| Act.entryRelationship:entryRelationship1.observation.value | preferred | CareModel |
| Act.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Act.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-priorityCode | warning | Act, Act.entryRelationship:entryRelationship1.observation | SHOULD contain priorityCode : priorityCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:indication.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Path | Conformance | ValueSet / Code |
| Act.nullFlavor | required | CDANullFlavor |
| Act.typeId.nullFlavor | required | CDANullFlavor |
| Act.templateId:patient-referral-act.nullFlavor | required | CDANullFlavor |
| Act.classCode | required | Fixed Value: PCPR |
| Act.moodCode | required | PatientReferralActMoodCode |
| Act.code | required | ReferralTypes |
| Act.text.nullFlavor | required | CDANullFlavor |
| Act.text.compression | required | CDACompressionAlgorithm |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Act.text.mediaType | example | MediaType |
| Act.text.representation | required | BinaryDataEncoding |
| Act.statusCode | required | ActStatus |
| Act.statusCode.nullFlavor | required | CDANullFlavor |
| Act.priorityCode | example | ActPriority |
| Act.languageCode | required | AllLanguages |
| Act.participant.nullFlavor | required | CDANullFlavor |
| Act.participant.typeId.nullFlavor | required | CDANullFlavor |
| Act.participant.typeCode | required | Fixed Value: REFT |
| Act.participant.contextControlCode | required | Fixed Value: OP |
| Act.participant.participantRole.nullFlavor | required | CDANullFlavor |
| Act.participant.participantRole.typeId.nullFlavor | required | CDANullFlavor |
| Act.participant.participantRole.classCode | required | RoleClassRoot |
| Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Act.entryRelationship:entryRelationship1.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: SUBJ |
| Act.entryRelationship:entryRelationship1.observation.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.classCode | required | Fixed Value: OBS |
| Act.entryRelationship:entryRelationship1.observation.moodCode | required | Fixed Value: RQO |
| Act.entryRelationship:entryRelationship1.observation.code | example | ObservationType |
| Act.entryRelationship:entryRelationship1.observation.code.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.statusCode | required | ActStatus |
| Act.entryRelationship:entryRelationship1.observation.statusCode.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
| Act.entryRelationship:entryRelationship1.observation.languageCode | required | AllLanguages |
| Act.entryRelationship:entryRelationship1.observation.value | preferred | CareModel |
| Act.entryRelationship:entryRelationship1.observation.interpretationCode | required | ObservationInterpretation |
| Act.entryRelationship:entryRelationship1.observation.methodCode | example | ObservationMethod |
| Act.entryRelationship:entryRelationship1.observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Act.entryRelationship:indication.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Act.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-priorityCode | warning | Act, Act.entryRelationship:entryRelationship1.observation | SHOULD contain priorityCode : priorityCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:indication.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 7 elements (7 nested mandatory elements)
Fixed Value: 8 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-priorityCode: SHOULD contain priorityCode should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
| templateId:patient-referral-act | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.140 | |
| @extension | 0..0 | |||
| @classCode | 1..1 | cs | Fixed Value: PCPR | |
| @moodCode | 1..1 | cs | Binding: Patient Referral Act moodCode (required) | |
| id | 1..* | II | In the case of a Consultation Note where this referral is being fulfilled by this consultation, this id would be referenced in the inFullfilmentOf/order/id of the Consultation Note. | |
| code | 1..1 | CD | Binding: Referral Types (required) | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the time when the future referral is intended to take place. | |
| priorityCode | 0..1 | CE | ||
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| participant | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Fixed Value: REFT | |
| participantRole | 1..1 | ParticipantRole | ||
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). Slice: Unordered, Open by profile:observation | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents whether the referral is for full or shared care. | |
| @typeCode | 1..1 | cs | Fixed Value: SUBJ | |
| observation | C | 1..1 | Observation | should-priorityCode: SHOULD contain priorityCode |
| @classCode | 1..1 | cs | Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Fixed Value: RQO | |
| code | 1..1 | CD | ||
| @code | 1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| statusCode | 1..1 | CS | ||
| @code | 1..1 | cs | Fixed Value: completed | |
| priorityCode | 0..1 | CE | Binding: ActPriority (preferred) | |
| value | 1..1 | CD | Binding: Care Model (preferred) | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Fixed Value: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.moodCode | required | PatientReferralActMoodCode |
| Act.code | required | ReferralTypes |
| Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
| Act.entryRelationship:entryRelationship1.observation.value | preferred | CareModel |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-priorityCode | warning | Act, Act.entryRelationship:entryRelationship1.observation | SHOULD contain priorityCode : priorityCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Act | C | 1..1 | Act | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, @negationInd, id, code, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1 Base for all types and resources Instances of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value should-priorityCode: SHOULD contain priorityCode should-author: SHOULD contain author |
| Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root | |
| templateId:patient-referral-act | 1..1 | II | ||
| @root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.140 | |
| @classCode | 1..1 | cs | Binding: XActClassDocumentEntryAct (2.0.0) (required) Fixed Value: PCPR | |
| @moodCode | 1..1 | cs | Binding: Patient Referral Act moodCode (required) | |
| id | 1..* | II | In the case of a Consultation Note where this referral is being fulfilled by this consultation, this id would be referenced in the inFullfilmentOf/order/id of the Consultation Note. | |
| code | 1..1 | CD | Binding: Referral Types (required) | |
| text | 0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |
| reference | C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: active | |
| effectiveTime | 1..1 | IVL_TS | The effectiveTime represents the time when the future referral is intended to take place. | |
| priorityCode | 0..1 | CE | Binding: ActPriority (example) | |
| author | 0..* | AuthorParticipation | Base for all types and resources | |
| participant | 0..* | Participant2 | ||
| @typeCode | 1..1 | cs | Binding: ParticipationType (required) Fixed Value: REFT | |
| participantRole | 1..1 | ParticipantRole | ||
| @classCode | 1..1 | cs | Binding: RoleClassRoot (required) | |
| code | 0..1 | CE | Binding: Healthcare Provider Taxonomy (preferred) | |
| Slices for entryRelationship | 0..* | EntryRelationship | The following entryRelationship represents a reference to another act in the document instance representing the clinical reason for the referral (e.g., problem, concern, procedure). Slice: Unordered, Open by profile:observation | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | The following entryRelationship represents whether the referral is for full or shared care. | |
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |
| observation | C | 1..1 | Observation | should-priorityCode: SHOULD contain priorityCode |
| @classCode | 1..1 | cs | Binding: ActClassObservation (2.0.0) (required) Fixed Value: OBS | |
| @moodCode | 1..1 | cs | Binding: XActMoodDocumentObservation (2.0.0) (required) Fixed Value: RQO | |
| code | 1..1 | CD | Binding: ObservationType (example) | |
| @code | 1..1 | cs | Required Pattern: ASSERTION | |
| @codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.5.4 | |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| @code | 1..1 | cs | Fixed Value: completed | |
| priorityCode | 0..1 | CE | Binding: ActPriority (preferred) | |
| value | 1..1 | CD | Binding: Care Model (preferred) | |
| entryRelationship:indication | 0..* | EntryRelationship | ||
| @typeCode | 1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |
| observation | C | 1..1 | Indication | Base for all types and resources |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Act.classCode | required | Fixed Value: PCPR |
| Act.moodCode | required | PatientReferralActMoodCode |
| Act.code | required | ReferralTypes |
| Act.statusCode | required | ActStatus |
| Act.priorityCode | example | ActPriority |
| Act.participant.typeCode | required | Fixed Value: REFT |
| Act.participant.participantRole.classCode | required | RoleClassRoot |
| Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Act.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: SUBJ |
| Act.entryRelationship:entryRelationship1.observation.classCode | required | Fixed Value: OBS |
| Act.entryRelationship:entryRelationship1.observation.moodCode | required | Fixed Value: RQO |
| Act.entryRelationship:entryRelationship1.observation.code | example | ObservationType |
| Act.entryRelationship:entryRelationship1.observation.statusCode | required | ActStatus |
| Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
| Act.entryRelationship:entryRelationship1.observation.value | preferred | CareModel |
| Act.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Act.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-priorityCode | warning | Act, Act.entryRelationship:entryRelationship1.observation | SHOULD contain priorityCode : priorityCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:indication.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Path | Conformance | ValueSet / Code |
| Act.nullFlavor | required | CDANullFlavor |
| Act.typeId.nullFlavor | required | CDANullFlavor |
| Act.templateId:patient-referral-act.nullFlavor | required | CDANullFlavor |
| Act.classCode | required | Fixed Value: PCPR |
| Act.moodCode | required | PatientReferralActMoodCode |
| Act.code | required | ReferralTypes |
| Act.text.nullFlavor | required | CDANullFlavor |
| Act.text.compression | required | CDACompressionAlgorithm |
| Act.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Act.text.mediaType | example | MediaType |
| Act.text.representation | required | BinaryDataEncoding |
| Act.statusCode | required | ActStatus |
| Act.statusCode.nullFlavor | required | CDANullFlavor |
| Act.priorityCode | example | ActPriority |
| Act.languageCode | required | AllLanguages |
| Act.participant.nullFlavor | required | CDANullFlavor |
| Act.participant.typeId.nullFlavor | required | CDANullFlavor |
| Act.participant.typeCode | required | Fixed Value: REFT |
| Act.participant.contextControlCode | required | Fixed Value: OP |
| Act.participant.participantRole.nullFlavor | required | CDANullFlavor |
| Act.participant.participantRole.typeId.nullFlavor | required | CDANullFlavor |
| Act.participant.participantRole.classCode | required | RoleClassRoot |
| Act.participant.participantRole.code | preferred | HealthcareProviderTaxonomy (a valid code from http://nucc.org/provider-taxonomy) |
| Act.entryRelationship:entryRelationship1.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.typeCode | required | Fixed Value: SUBJ |
| Act.entryRelationship:entryRelationship1.observation.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.classCode | required | Fixed Value: OBS |
| Act.entryRelationship:entryRelationship1.observation.moodCode | required | Fixed Value: RQO |
| Act.entryRelationship:entryRelationship1.observation.code | example | ObservationType |
| Act.entryRelationship:entryRelationship1.observation.code.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.statusCode | required | ActStatus |
| Act.entryRelationship:entryRelationship1.observation.statusCode.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.priorityCode | preferred | ActPriority |
| Act.entryRelationship:entryRelationship1.observation.languageCode | required | AllLanguages |
| Act.entryRelationship:entryRelationship1.observation.value | preferred | CareModel |
| Act.entryRelationship:entryRelationship1.observation.interpretationCode | required | ObservationInterpretation |
| Act.entryRelationship:entryRelationship1.observation.methodCode | example | ObservationMethod |
| Act.entryRelationship:entryRelationship1.observation.referenceRange.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.referenceRange.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:entryRelationship1.observation.referenceRange.typeCode | required | Fixed Value: REFV |
| Act.entryRelationship:indication.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavor |
| Act.entryRelationship:indication.typeCode | required | Fixed Value: RSON |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Act | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Act.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-priorityCode | warning | Act, Act.entryRelationship:entryRelationship1.observation | SHOULD contain priorityCode : priorityCode.exists() | |
| should-text-ref-value | warning | Act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Act.entryRelationship:indication.observation | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Act.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
This structure is derived from Act
Summary
Mandatory: 7 elements (7 nested mandatory elements)
Fixed Value: 8 elements
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-21
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